435201842-5-13-2025-26-AS-MMOR-DGMUCK-20250513152804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201842
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:28:21 PM

Document Has Been Signed on 05/13/2025 03:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	EDWARD CARE HOME		FACILITY NUMBER:	435201842
ADMINISTRATOR/ DIRECTOR:	QUINTIN H. ZACARIAS		FACILITY TYPE:	735
ADDRESS:	1315 BECKET DRIVE		TELEPHONE:	(408) 224-9988
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 6		CENSUS: 4	DATE:	05/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:35 PM
MET WITH:	Staff Leticia Antonio		TIME VISIT/ INSPECTION COMPLETED:	03:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff, S1, Leticia Antonio. S1 contacted Facility ADM. ADM stated he could not come to the facility due to a family emergency. ADM stated S1 could sign on his behalf. During the visit, LPA observed 1 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 112 degrees F in both resident bathrooms. During the tour of the facility, LPA observed several physical plant issues. LPA observed a rusty shower curtain rod in the facility hallway bathroom closest to the kitchen. (Photograph was taken.) LPA also pointed out the plastic flooring/base at the shower is beginning to degrade, resulting in the black spots. LPA also noted stains on the shower walls and at the base of the shower. While touring the resident bedroom closest to the backyard shed, LPA observed a hole in the door. (Photograph was taken.) While touring the backyard, LPA observed two of the wooden planks of the fence, next to the storage shed, were no longer attached to the fence, creating an opening. Page 1 Out of 2.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EDWARD CARE HOME	FACILITY NUMBER: 435201842
	VISIT DATE: 05/13/2025

NARRATIVE

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Fire extinguisher was serviced in October 11, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 3, 2025.

LPA reviewed facility records for 3 staff and 3 residents. LPA requested to review staff S2's Health screening, LIC503. LPA was provided with two copies (Photographs taken.), but neither was signed by the person performing the screening

LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 1 resident.

LPA reviewed 3 residents P&I records. R1 P&I log stated R1 had a balance of $1142.63. After staff S1 counted the P&I, R1's total P&I funds were $1142.77. (Over 14 cents.) R2's P&I log stated R2 had a balance of $1514. Staff S1 counted R2's funds, which totaled to $1524.10. (Over 10 dollars and 10 cents.)
R3's P&I log stated R3 had a balance of $90. Staff S1 counted R3's funds, which totaled to $90.90. (Over 90 cents.) LPA and staff S1 reviewed and audited residents R1-R3's P&I records. All 3 residents had discrepancies between the total physical funds and the P&I log.

Deficiencies are being cited during today's visit. This report was reviewed with Staff Leticia Antonio and a copy of the signed report was provided.

Page 2 Out of 2. END OF REPORT.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 05/13/2025 03:28 PM - It Cannot Be Edited

Created By: Manuel Monter On 05/13/2025 at 03:07 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EDWARD CARE HOME	FACILITY NUMBER: 435201842
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed a rusty shower curtain rod, stains in the shower walls and the plastic base at the shower is beginning to degrade hallway bathroom closest to the kitchen. Resident bedroom closest to shed, had a hole in the door. LPA observed fence had two opening due to missing wooden planks. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/20/2025
	Plan of Correction
1 2 3 4	ADM stated he will send a written plan of action on how he will ensure The facility shall be clean, safe, sanitary and in good repair at all times for residents in care. ADM stated he will send the written plan of action to LPA by POC date.

Type B

Section Cited

CCR

80070(b)(14)

Client Records

(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA and staff S1 reviewed and audited residents R1-R3's P&I records. All 3 residents had discrepancies between the total physical funds and the P&I log. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/20/2025
	Plan of Correction
1 2 3 4	ADM stated he will send a written plan of action on how he will ensure the facility has an accurate account of residents cash resources. ADM stated he will send the written plan of action to LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/13/2025 03:28 PM - It Cannot Be Edited

Created By: Manuel Monter On 05/13/2025 at 03:09 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EDWARD CARE HOME	FACILITY NUMBER: 435201842
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80065(g)(2)

80065 Personnel Requirements(g)(2) A health screening report signed by the person performing such screening shall be made on each person specified above, and shall indicate the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above. LPA requested to review staff S2's Health screening, LIC503. LPA was provided with two copies, but neither was signed by the person performing the screening. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/20/2025
	Plan of Correction
1 2 3 4	ADM stated he will send a copy of Staff S2's completed health screening to LPA by POC date, May 20, 2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

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